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CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Discuss the growing demand for telepsychology services.
- Discuss the common pitfalls for psychologists who offer telepsychology services.
- Discuss the types of guidance offered by APA's Guidelines for the Practice of Telepsychology.
When psychologist Keren Chansky Suberri, PhD, moved her practice from southern New Jersey to Philadelphia in 2015, she didn't worry about finding office space convenient for her clients—primarily families of children with health-care problems. That's because she switched from in-person meetings to videoconferencing.
"I had become acutely aware that families' needs weren't being met because parents of children with special health-care needs weren't able to get to my office," says Suberri. It can be difficult for families of children with diabetes, seizure disorders and other serious issues to find appropriate childcare, she says. Plus, parents who've already taken a lot of time off for their children's medical appointments are often reluctant to take off more to see a psychologist. Others simply live far too far away to make regular visits.
Suberri's other clients like videoconferencing, too.
The technique works well with clients with agoraphobia, for instance, for whom "just going out of the house and into a doctor's setting is like climbing the Himalayas," says Suberri. Other clients appreciate the privacy of meeting with Suberri virtually from their own homes or offices. And, says Suberri, "For the younger generation, this is very natural."
Offering guidance to psychologists like Suberri who offer telepsychology services is the goal of APA's Guidelines for the Practice of Telepsychology. Adopted as APA policy in 2013, the guidelines lay out the issues psychologists should consider when providing services through telecommunication technologies. The guidelines, which offer evidence-based recommendations rather than mandatory requirements, cover such issues as how to assess whether telepsychology is appropriate, obtain informed consent, protect patient confidentiality and legally work across jurisdictions.
But many practitioners still aren't aware of the guidelines, says Linda Campbell, PhD, a University of Georgia professor in the counseling psychology program who co-chaired APA's guidelines task force. "I still see people on listservs asking if there are any policies on how to practice telepsychology," she says. Some practitioners have dangerously mistaken beliefs about telepsychology, she and others say. For example, some clinicians use Skype and other unsecure platforms for videoconferencing, fail to adapt their informed-consent procedures or don't realize they need to be licensed in the states where their telepsychology patients live—all of which can put both patients and practitioners at risk.
Others may believe—falsely—that none of this applies to them, says task force co-chair Fred Millán, PhD, a private practitioner and psychology professor at the State University of New York at Old Westbury.
"Many don't understand they're already doing telepsychology," says Millán, explaining that the term encompasses telephone calls and emails as well as newer technologies such as chat, text and videoconferencing. And that lack of awareness can get people in trouble, he emphasizes. "If I'm a psychologist in New York and talking to my patient on the phone when that patient drives over the George Washington Bridge into New Jersey, that's now interjurisdictional practice," he says.
Meeting a growing demand
Demand for telehealth is growing. In a survey of 1,501 adults conducted by Nielsen on behalf of Accenture in 2016, more than two-thirds of respondents were at least somewhat interested in receiving health care virtually. When it came to mental health, 53 percent said they would probably or definitely try virtual counseling or therapy, while 50 percent said the same for virtual group therapy. Yet only 21 percent had received any health care virtually.
Psychology is now catching up with medical providers, who got started with telemedicine about a decade ago, says psychologist Marlene Maheu, PhD, executive director of the Telebehavioral Health Institute. APA's guidelines are speeding that process along, she says. "When groups like APA come out with formal guidelines, it in essence legitimizes a practice in the eyes of the average practitioner," she says.
State policies are catching up to telepsychology's growing popularity, too, says Deborah Baker, JD, director of legal and regulatory policy in APA's Practice Directorate. While insurance companies typically look to Medicare as a model when making decisions about coverage, reimbursement and other issues, that hasn't worked in the telepsychology arena, says Baker. Medicare reimburses telehealth services only if they're provided to beneficiaries in rural areas or areas with health professional shortages and only when people receive the services in a clinical setting rather than their homes.
In the absence of a Medicare guidepost, insurers have made their own decisions, says Baker. Now a growing number of states are taking charge: 31 states and the District of Columbia have enacted mandates prohibiting insurers from refusing to cover telehealth services if they cover the same services delivered in person.
Putting the guidelines into practice
The guidelines offer guidance on several key issues:
Competence. Psychologists who provide telepsychology services should take reasonable steps to ensure they know what they're doing, both in terms of technology and its potential impact, the guidelines say. With technology evolving quickly, one-off training isn't enough, says task force member Jana N. Martin, PhD, chief executive officer of The Trust. What was top-of-the-line technology a year ago may no longer be, she warns. "You might think, ‘I attended a workshop on how to use this encryption site, so I'm good,'" she says. "But we need to keep alert to how changes in technology, encryption and cyberattacks might impact the delivery of safe, confidential therapy."
Practitioners should also ensure their clients are tech-savvy, adds Campbell. "You don't want a client sending a confidential communication to a listserv by mistake," she says.
Standards of care. The guidelines urge psychologists to ensure they meet the same ethical and professional standards required for in-person services. Sometimes that may mean not using telepsychology. While a growing body of evidence suggests that some forms of telepsychology can be just as effective as their in-person counterparts, it's not appropriate for all clients, says Martin. Telepsychology may not be a good fit for some individuals, some diagnoses or some age groups, such as very young children, she points out.
The psychologist's level of experience with telepsychology and the level of other support available are key factors in the decision, says Martin. Psychologists using telepsychology with patients with schizophrenia or psychosis who are in a clinically supervised patient site have less risk than psychologists providing telepsychology to patients with similar diagnoses in an unsupervised setting, such as patients' homes, she says. "It can be stressful and challenging for a provider who is new to telehealth to manage a difficult patient with a new modality," says Martin. "Psychologists benefit from fully examining the best fit for each patient, looking at many factors."
Confidentiality and data security. Three of the guidelines focus on the special privacy concerns inherent in using technology. Psychologists, these guidelines recommend, should make reasonable efforts to safeguard confidentiality and warn clients of the potentially increased risks, put security measures in place to protect information and dispose of data and technology properly. That means psychologists should never use Skype or FaceTime—which is news to many practitioners, says task force member Ronald S. Palomares, PhD, an assistant professor of school psychology at Texas Women's University. "People aren't thinking about the fact that when they click on ‘I agree' in these apps, you're basically agreeing to turn over all transmissions to the parent company," says Palomares. "People aren't aware that their sessions could be recorded and released."
Fortunately, says Palomares, more platforms are being developed that comply with the Health Insurance Portability and Accountability Act (see "A growing wave of online therapy" in the February Monitor). But as this technological "arms race" accelerates, he says, it's up to practitioners to ensure compliance. They should also insist on business associate agreements with these companies, just as they would for a billing company or legal firm.
Informed consent. Informed consent should address the unique concerns related to telepsychology, the guidelines say, adding that psychologists should also know the laws and regulations that apply to informed consent in both their own and their clients' jurisdictions. In addition to covering the potential privacy risks of telepsychology, the informed-consent process could also include an explanation of how clients' information will be stored, accessed and protected. Another important area to include is what happens—including billing—after technology failures. "What if the image pixelates or the sound drops out?" says Maheu. "You need to cover that and have a plan."
Testing and assessment. Most test instruments and assessment approaches were designed for in-person use, the guidelines note. As a result, the guidelines urge psychologists using telepsychology for these purposes to find ways to maintain the integrity of testing. "You don't know if an individual may be getting answers or assistance from someone in the room you can't see," says Martin. One way to address those concerns is to have an onsite proctor—known as a "telepresenter" in the telehealth community—who can also provide any technical assistance a client may need, the guidelines suggest.
Cross-jurisdictional practice. Psychologists must comply with laws and regulations in the states, provinces or countries where their clients are, the guidelines note. While the Department of Defense and Department of Veterans Affairs have policies that govern cross-jurisdictional services, states, provinces and countries vary. For Suberri, that has meant getting licensed in the 10 states where she provides telepsychology services—an expensive, time-consuming process, thanks to the lack of uniformity in requirements.
The Association of State and Provincial Psychology Boards is trying to solve the interjurisdictional practice problem by developing the Psychology Interjurisdictional Compact (PSYPACT), which would allow licensed psychologists to offer telepsychology services in participating states without having to get licensed in those additional states. "Licensing requirements across states vary," says Janet Orwig, MBA, PSYPACT's executive director. "PSYPACT levels requirements across states and sets a bar." Arizona has already enacted PSYPACT legislation, and several more states have introduced legislation to adopt the compact, says Orwig. PSYPACT will become operational once it is enacted in seven states, something Orwig hopes will be achieved by year's end.
To directly access the citations in this article, go to our digital edition at www.apa.org/monitor/digital.
A Practitioner's Guide to Telemental Health: How to Conduct Legal, Ethical, and Evidence-Based Telepractice
Luxton, D.D., Nelson, E., & Maheu, M.M., 2016
A Telepsychology Casebook: Using Technology Ethically and Effectively in Your Professional Practice
Campbell, L., Millán, F., & Martin, J., eds., forthcoming
Critical Concerns When Incorporating Telepractice in Outpatient Settings and Private Practice
Palomares, R.S., Bufka, L.F., & Baker, D.C. Journal of Child and Adolescent Psychopharmacology, 2016
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